 All right. I'm going to go ahead and get us started. Good evening, everyone. Welcome to Conversations About Ethics. I'm Ruth Bergeron, Director of the Center for Medical Humanities and Ethics. Today's daytime workshop and evening keynote represent the 15th installment of Conversations About Ethics, the series, which explores ethical dilemmas that influence health care delivery throughout the life cycle. Conversations About Ethics is presented twice annually by the Ecumenical Center, our partner, and the Center for Medical Humanities and Ethics here at the Health Science Center through the generous support of Methodist health care ministries. So to anyone from those partner organizations who are here tonight, we greatly appreciate you. Before we get started, I do have a few brief housekeeping details. Dr. America Bracho and the Planning Committee have disclosed no relevant financial relationships with any commercial activities related to this evening's presentation. If you are seeking continuing education credit, please be sure to sign in at the appropriate desk out there as a record of your attendance. Those that seek CME credit should have received two pieces of paper on the way in. Please fill out the smaller paper. Return it to us as you leave. The larger paper is for you to keep. It has instructions on how to claim your credit from the CME website, which you'll do two to four weeks from now. So you'll have a follow-up internet task to do in two to four weeks for your CME. Now for CEU credit, please fill out the survey provided at the sign in and return it at the CEU desk before you leave, and you'll get your certificate at that time. Any details can be clarified by one of our volunteers as you exit the event. They're at education tables back there in the foyer. All right, to everyone here tonight, we really do value your feedback, and we ask you to thoughtfully evaluate this evening's program. And you can do that by using the QR code or the link that's on the back of your program with your smartphone. Tonight's presentation is titled Patients and Promotores as Partners in Improving Community Health. Promotores, also called community health workers, are a growing presence in health care, particularly in this region. Through shared ethnicity, language, and culture, these trusted community members form one-on-one relationships with those they serve. They fill many roles, including health educator, advocate, and navigator of our healthcare systems complexities. Our speaker, Dr. America Bracho, is a leading public health expert and director of Latino Health Access, a Center for Health Promotion and Disease Prevention in Santa Ana, California. Latino Health Access seeks to empower the Latino community and uses participatory approaches to community health education. It also trains promotores as leaders of wellness and change. Dr. Bracho worked as a physician in her native Venezuela, before coming to the United States to receive a Master of Public Health degree at the University of Michigan. She specializes in health education and health behaviors, something that we are very interested in here in San Antonio. All of you, please help me welcome America Bracho. Good afternoon. I think this is on, is this on? Yes? No? He's on? Okay. Is it right? Well, now. Now, okay. So good evening, and thank you so much for joining us in this conversation. It is my pleasure to be here sharing this short time with people that are also involved in making our communities better places and taking care of our community. So it's a privilege. As Ruth said, I am from Venezuela, where I was trained as a physician and worked as a physician for several years in rural Venezuela. And I love to start there, and that's actually Venezuela, and that is my house, and I swim there every year. I'm going there at the end of April with a lot of problems. Venezuela right now doesn't have even antibiotics, I mean it's horrible. The crisis that we are living is terrible, and I could talk about that for days. We don't have toilet paper, sugar, bread, disaster. But in any case, it's my home country, and then this is my other home country. And while working in Venezuela as a physician in rural Venezuela, I was confronted with a lot of situations in which our patients would come to us with the same disease every week. So I would see kids with a different diarrhea every week, but diarrhea every week. With tuberculosis, with malaria. Very difficult, you know, and just to be there, feeling that of course you are helpful, but you are working with conditions that could be prevented. And that they could be prevented if we work in the systems that need to be improved for those conditions to be prevented. Otherwise, I felt I was trapped. I was trapped in doing the same, the same, the same, and I decided to go into public health. So of course we did a lot of community work there, and in Venezuela I met the first community workers of my life. You might or might not recall that in 1978, during the gathering of Alma Ata in what was then the Soviet Union, the World Health Organization said, invited the world to include community members in their teams as a way of improving access. The World Health Organization said, you know, well they don't talk like that, but I imagine talking like that, you know, they said, you guys, guess what? We have a lot of specialty care that is not reaching the majority of the people. We have a lot of technology that is not reaching the majority of people. And this is not going to improve unless we move to primary care. And it became the primary care declaration of Alma Ata. And in that primary care they started talking and giving emphasis to family practitioners, to nurse practitioners. And to this special worker that they call community workers and have been known in Latin America as promotores, promoters, the ones that promote for many, many years. So when I graduated, we had promotores in Venezuela. And I had the opportunity to experience firsthand the difference that it makes to have the person that lives in that town and knows everyone dealing with immunizations. And going house by house, knocking at those doors and saying, Maria! And Maria will answer from the end of the house, que hubo! And she will say, bring the kids. Why? Because they need the vaccines. I'm busy, I don't care. Bring the kids. You know, and this relationship that allowed these promotoras to have 100% of coverage. And when I came to Orange County where Disneyland is, in zip codes that are very poor in Orange County, we had less than 50% of kids immunized. In a county with resources, in a county that by itself could be one of the richest countries in the world. And we had a bunch of kids without immunization and families suffering unnecessarily because lack of access to resources. Which again, since these are our conversations on ethics, probably that would be one of my first points. You know, is it right to have that amount of resources and just distribute them in a way that you want that makes sense for you, but really that keeps low income people and underserved people sick or at risk. So, well, I went to do my public health training and then I became the director of eight programs in Detroit in the time when this was not called HIV, it was called AIDS. And AIDS, the AIDS epidemic, which later became the HIV epidemic, was an incredible feature for us. Because as they say, AIDS was part of the problem, but AIDS was able to tell us where the problems were. Problems in terms of accepting how people are or their behavior and that clear connection between a behavior that is judged and the epidemic going on the ground. So you don't want to deal with that, it's not going to disappear. It's going to go on the ground. Like, you know, like the substance abuse epidemic, it goes on the ground. In public health, we don't judge. Maybe because a virus doesn't have a passport or visa and it doesn't allow, you know, it doesn't ask for permission to enter your country. You know, it is what it is. And we have to see it with different lenses. So anyway, but during that epidemic, I remember that the emphasis was in condom use, which to this day, that's the emphasis. And we were seeing women that were victims of rape, women that didn't know how to read and write, that were victims of domestic violence and the perpetrator was the one paying the rent. So it was complicated to just talk about condoms. It almost felt like you were denying the right information to the people that would allow them to make decisions just because the system decided that the priority was the condom. And I equated condom with the water that we prepare to treat diarrhea is water with sugar and salt. And that's what you do. You have diarrhea, you prepare that little water and you teach people how to prepare the water. And I say, well, we are just replacing like the water concept with the condom. Just treat that, don't mess with the reasons why these diseases are being generated. So then I went to California where I started Latino Health Access to fight some of these inequities. So in Latino Health Access after 23 years, we have been working in really creating a philosophical framework that can guide our work understanding our own best practices, elevating our practices and it's not simple because you always have a dominant paradigm that is telling you do it this way, the way you were talking medical school. If you do it the community way is not professional. If you do it the community way might not be that scientific. So just to go and to say the community since the world started has been part of the solution. My grandma, my abuela, your grandma, your aunts, your neighbors have been part of the solution. And there has to be a way in which we validate the power of communities in making societies healthier places for all. So we started doing the work and understanding why it was having good results. So this is our first principle of practice. We believe in the definition of health from the World Health Organization. In which health is a state of physical, mental and social well-being and not just the absence of disease. Which means that sometimes in order to improve the health of the community, you need to activate the vote. We need to activate the Latino vote so we can get policies passed that at the end will impact the life of those communities. So working on health policy becomes an incredible part of health. Education is health. So the World Health Organization pretty much says that, we endorse that. And they say also, I wanted to share this because again this is about ethics. And the World Health Organization says that health is a fundamental right as opposed to saying that health is a privilege. Health is a right. And once you agree that health is a right, it's a different game. They also say that they affirm the dignity and worth of every person and the equal rights, equal duties and shared responsibilities for health. Which means that you have a right to health. But you also have a duty. And if that is true, if each of us has the duty to health, are we actually having mechanisms to practice our duty? So our duty, how does it come? What is the form of that duty? Just making sure you do what your doctor says? Is that the extent of the practice of our duty? Is that our duty to do things that keep us healthy, that keep our families healthy? Is that our duty to keep our communities healthy? Is it? Or there is a group that has those duties. That's it. This is a group of selected few that actually have this thinking role, an activist role in making our planet healthier. But not you, or you, or you. You don't belong to that. Hmm, they say that they are committed to the ethical concept of equity, solidarity and social justice, and to the incorporation of a gender perspective in their strategy. And we are talking about the world of organization. We are not talking about an extremist political party or, and this is the world of organization. Because the world of organization now understands that without that, the majority of the people of the world will not have health. At the end of the day, will not. And they say that it is extremely important to reduce social and economic inequities. And to pay attention to those most in need. And we are going to check on that again in a little while. The United States then, so this is the world of health organization, then the United States talk about health disparities and it's not the only country that talks about health disparities. But health disparities have to do with all of those social determinants that are making you sick. So what is compared? You compare the mainstream people in New Zealand with the aboriginal people in New Zealand. And you are going to find that in comparison with the white people in New Zealand, the aboriginals have huge disparities. They live less time, the life expectancy is shorter. And here is the same. We have huge disparities that are racial disparities, economic disparities. And there is a lot of science behind this saying that this is not just genetic. So you can find disparities in the African-American community. On diabetes, on low birth weight, double, triple, amount of kids that are born with low birth weight that in the white community. You find disparities among kids. Asthma, obesity, depression. A lot of disparities among Latinos and you can check this. And you have, my presentation is available to all of you. It's right there in that computer. So if you are interested, you can have it. So a lot of disparities regarding diabetes and heart disease. So again, the community that is going blind at 40. A community that is amputated at 38. You know, you are talking about kids in the American Indian population. You are talking about a tribe where 12 kids committed suicide in the last four months. We don't even hear about that. How is that possible? There are communities where if one kid commits suicide, the entire community stops. And you can have 12 kids killing themselves and nothing happens. Nothing happens, but we need to ask ourselves why nothing happens? Where is it? If it's not technical, because technically this is what our understanding and we have the statistics, so we are even documenting that, then what is it? Is it that we have a paradigm in which that doesn't matter? Is it that the people in power somehow, in power somewhere in the institutions are not giving a priority to this population? Is it possible that the fact that the population affected is not at the table has something to do with it? And what would happen if they are at the table? I have learned so much in the difference that it makes when I sit with powerful people alone, America baracho with them, and what they say about our community. And when I bring the moms into the room, how the conversation changes. And they don't dare to say half of what they said when they were not in the room. And again, the same happens with Asian Americans. I mean, the parties for lesbian, gay, bisexual, transgender, also high rate of suicide and infections and again, all of these disparities. This system is pretty expensive. The healthcare system in the US is super expensive and is one of the worst in terms of outcomes among the industrialized world. A lot of room for improvement. So how come we spend so much money? And then how is the money being used, right? So I'm going to give you some examples on how it looks on the ground. In Oakland, California, if you are born an African American and you live in one side of Oakland, you can expect to die 15 years earlier than a white person in the other side of Oakland. 15 years. When you talk about health disparities, my friends, the currency is years of life. It has been said that in order to predict your life expectancy, your zip code has more power than your genetic code. You can see the same in social service. You can see where are the kids being removed. And you will find that the amount of kids removed from their homes to be placed in foster care are concentrated in 60-something zip codes in the nation, overrepresented. So if you increase the income by $12,000, you get one more year. So what is happening in those communities where these kids are living and where this community is having 15 years less of life? So let's go to Orange County, where we work. And you are going to see that there are 10, the 10 poorest zip codes, and Santa Ana has four of them. The 9-2-7-0-1, where we have concentrated our work, is the second poorest in the county, and one of the poorest in the state of California. But I want you to think the following. It's not the zip code. It's the place in that zip code. Someone gave me feedback, it was changed with me. We did a workshop of four hours today, and she was sharing with me, you made me think, she said, that my hospital, and I don't remember what is the name of her hospital, here in San Antonio, is in one of the poorest zip codes here. And a lot of this data is surrounding her hospital. She's not very sure that the hospital is doing anything to improve the outcomes in the communities surrounding the hospital. Should the hospital do something? Does it matter? It matters for sure now for quality measures. Without paying attention to population health, you are going to have this cluster of people in your hospital that will not improve. And with the new changes in healthcare reform, that will be translated in less income. So you can do it for that reason, or you can do it because we have to do it. Somehow we have to pay attention to those sources of disease and despair. I wanna share with you that this is Orange County, and this is Santa Ana, and in this area you have more than half of the youth of Orange County. Low income Latinos. I'm going to move now to our work. And in that same area, you have the concentrated poverty among adults. You have concentrated the amount of adults that do not have high school. Concentrated poverty among kids. Concentrated obesity among kids. And if you see obesity on top of poverty, that's what you get. You see Irvine here, and you see Santa Ana here. But it's not just, it's not Santa Ana, it's a place in Santa Ana. It's a place. And it has been said that the place where you live, where you play, where you learn, and where you work has everything to do with your health. Everything to do. So when people say, I mean, if you want to succeed, you can. It's up to you. It's up to your kids to just succeed without paying attention to that school, to that environment, which is really shaping the opportunities for those kids. So pedestrian injury, one of the highest rates is Santa Ana, and you put this in the morning, and then they put this in the afternoon. And then you have this sign. Right? So now, move away from the statistics and the numbers and welcome to the neighborhood, to the hood, to the place. This is the place. It's not just the 9271, this is the place. This is the place. A place that when we did our first survey in 1996, the neighbors said that they didn't have a single park. Not one park for 65,000 people. And I asked one of the politicians in town about this, and he said, well, you are lucky, you have the zoo. Well, whatever, you can have a conversation about that answer, right? But I don't want to go there, you know? Or where your kids play, and if your kids play in the zoo, or who should be in the zoo? Anyway, so in any case, the fact that we have liquor stores, after liquor stores and signs of liquor stores, what is telling, what is the environment telling you in terms of the priority of this population? Is this fair? Is this right? Is this just? Who is making the decisions here about bombarding this community with disease marketing? No places to play. And this is an old slide. I took that in 2004, and it has been around the planet. It says passive area, not active sports. That sign was removed. Steel is one of those little places called park. So this is a park that is a passive area. So much for obesity. You know, how many calories can you burn there? You know? So this is a building where our community lives, and these are the signs that you see in the building. This is the face of the pedestrian injury that arrives to the hospital. And these are the kids playing in dumpsters. And dumpsters, or trespassing. Trespassing because the schools are closed after certain hours. So what you are seeing here is what in public health is called the social determinants. The social determinants. So my kids are as Latinos as these kids. The Latina woman married with a Latino man. Latino kids, that look like me, you know? My kids went to private school and had many other opportunities. And it is what it is. So it's not linked to your Latinismo. It is linked to something different. And so homelessness is increasing. So these are some of the determinants. Stress, discrimination, you know, economic disadvantage. And it has been demonstrated. Again, this is not America. I haven't shown, you know, we have a lot of data, but this is Healthy People 2020. And talking about how, you know, access to parks really has been associated with walking. If you have parks, you will walk. Even if arriving to that conclusion costs millions. Right for NIH research. That at the end is, if you have parks, people will play. Okay, good. I can do that for free. I can tell you that for free. And you know, that education is associated with longer life expectancy. Yes, my friends, it's demonstrated that discrimination actually can increase blood pressure. There is a report that is called On Natural Causes. That links racism and discrimination to chronic diseases. And family and community rejection, including bullying and all of that, has been associated with depression, use of illegal drugs, and suicide. So those are the determinants. And again, here we have our minds saying, okay, is that true? I don't believe that. Those are America's assumptions. Well, they are not my assumptions, although I assume a lot of things on YouTube. There's not one person here that doesn't assume something. You know? If I assume that the community should be at the table to make their voice heard, I assume that. And if that community is not at your table, you are assuming the opposite. But there is not a person that isn't in the no-assumption territory. Either I think our women in our community are poor and smart and brave. And other people might say, no, they are not. Well, let's say our assumption. And we have to start where we are, right? So the place where people live and eat affects their diet. Again, $1 million NIH grant, I can tell you that too. If I only can buy Cheetos, I'm going to eat Cheetos. If the water in my town can make you sick, I might drink Coca-Cola or another soda. You know? It will influence what I... And if the only thing I eat every day is a hamburger, then I will grow up preferring that. So... But the American Diabetes Association has estimated, for example, that diabetes is super expensive and it's costing a fortune to this country that 86 million people have pre-diabetes. 86 million people in this nation. And they don't know it. It's being called the tsunami of healthcare. People now are joining, are getting insurance, and they come with pre-diabetes and don't know it. But in order for them to actually prevent diabetes, they have to do two things. They have to lose weight, good luck. And they have to exercise. Now they need to know that they have pre-diabetes and they have to do it. So the Affordable Care Act pays for the follow-up. Screening and counseling for HIV, screening and counseling for depression, screening and counseling for obesity, screening and counseling. You know how much you can do with that? With screening and counseling? You know how many people are going to lose weight? Maybe some, right? How many? The majority? No. So whatever. This is what the Institute of Medicine says. It is unreasonable to expect from people to change when there are so many forces conspiring. So the proposal then is how do we allocate resources with an equity level? Because equity will be the reflection of a more just practice, right? If you look at this slide, you are going to see that here are the services. Let's say you provide counseling and screening for obesity. Let's imagine that that's what you are providing. And let's imagine that it's very accessible. People are enrolling your services, they will have counseling. So here is this person that got counseling and here are the other two. What is happening? They are receiving the same services, they are not. They are having, someone is presenting to them the possibility, that's it, but they cannot use it. They cannot use it. That group of people in your hospital, in your clinic that continues to have their hemoglobin A1C, which is one of the indicators of full control of diabetes, they are going to continue there even if you offer that. And what we need to do is to move here and say, okay, what is what that person needs? What this person needs to access that? And our job is to figure out these boxes. What is in that box? And the promotores are amazing in figuring out that box. And part of what that box needs to contain is the person's knowledge or civility and inclusion. So they can figure out with you what the box needs. So these are the advice. If you wanna fight inequity, you need to focus proactively in the population affected with social neglect. So, but the people that put together these programs in the series, sometimes they say, well, no, I need to approve this budget and it goes equal amount. Equal amount for Newport Beach, equal amount for Santana, equal amount in Santana for everybody, equal amount because we need to have equal access, equal access. And so Newport Beach, which has, or Lamuna Beach, that has less need, less poverty, get the same resources. Is that how it goes? And I'm going to leave it up to you to reach your own conclusions. But I think that we need to say, well, if we need to fight this and we need to reverse this and we need to improve healthcare, what is the best way of doing it? So you could say, well, I'm going to focus on policy, I'm going to run for senator, I'm going to run for president, I'm going to be concentrated in seeing patients. And we decided to concentrate in improving the participation of those communities that normally are not at the table. And see, what happened when you actually create mechanisms for people to be part of the solution? What happened when you then have your own autonomy, your own autonomy to decide what is what you want? When you can ask the questions, when you participate, not only with your doctor, but with your teacher, what happened when you are included? Well, a lot of things happened that I'm going to show you. But before I show you that, I want to tell you that there is a paradigm that can help us contemplate that and there is a paradigm that doesn't help us. And there is a paradigm here that can say these poor people really can they contribute? If they have a third grade education, can they? And if they can, am I going to have to spend two hours having a conversation with them because they are not at my level? Is it my job? I have been trained to tell them what to do. So there is a paradigm in which the providers tell people what to do and the community or the patients receive your knowledge and your advice. But then if people don't do what we say, we call them non-compliant. We say, we don't understand what's going on with these people that don't do what they need to do. We believe that patients should be participants. The other day I was invited to a conference and the question was, can you tell us more about what customers want? And I said, I cannot start answering that without replacing the word customer for the word participant because patients, customers and clients and I'm relearning how to talk as I relearn. I'm learning to dispose some words that are not helpful and replace them with the ones that are helpful. Really, a customer is about a transaction and what we are trying to create a relationship, not just transaction. I buy, have fond of cheese, you sell me the cheese, I'm your customer. A participant actually, as a concept, will obligate us to have a two-way communication, to develop a relationship. And sometimes we are trained, the majority of times we are trained not to create relationships. Because they are a burden. People might call you late at night and they will stop you and tell you their problems in any place. And we don't want relationships. We just want to finish and that's it. 15 minutes with each patient and that's the end of it. Promotores are experts in creating relationships. They actually give you their cell phones. We have promotoras that have crossed the border to Tijuana at three in the morning because a woman called them and said, you know what, you told me that he's going to kill me. I think he's going to kill me today. This morning I told him this, he's drinking, he will come back and he was going to kill me. And a promotora will take that woman across the border because that woman has her cell phone. And when we think about community workers and a community getting stronger, it won't get stronger because America Bracho who doesn't live in that community says so. I don't live there. And I act in solidarity and I talk about this and we write about this and we support salaries and we have 42 community workers doing that work but I don't live there. So when I go home, I go home. But for that promotora, that night is shooting in that neighborhood sometimes. And maybe in a week, she's going to be addicted. And you know, her son is coming with homework that she cannot help with. And the school is not helping either. So who should be at the table? If she sits at the table, the sense of urgency sits at the table. She needs to be at that table. And it's our role to support that voice. So she doesn't get intimidated when someone says, excuse me, what are your credentials and why are you at this table? And we have had a lot of that. And the promotoras now are responding, we are the CEO of this organization, the community expert organizer. So yes, patients as participants can be in many, many roles. You know, in the board of your hospital, of your university and advisory groups, they can be cultural brokers. The Institute of Medicine says that in order to fight obesity and really win this fight, we need families and individuals in leadership positions. It's not longer just eat better, that won't do it. It's not enough. It's not enough to just change diet, it's more. It's more input there. So we believe that participation makes a difference. This is one of our principles of practice. We have 18 principles of practice. And again, you can have this presentation. We also have a book that your organizers have allowed us to bring. It's the book of Latino Health Access and our practice where you can find all the principles as well. And one of the most interesting parts of writing that book, and I have the privilege of writing part of it and the introduction, was not even to share the things that I don't do right, that we don't do right. The most difficult part was actually to validate the community way. Where sometimes the community itself doesn't believe that what we are doing is valid. So this is our team, our board of directors, our promotores, 42 community workers. We have people with masters, with PhDs, and they are called the technical experts. And the community is called the community expert. This is the work of the promotores. Promotores will go and do outreach and they say, how can I invite you? How can I invite you if I don't know you? So I need to go and find you first. Then the second part, once I find you, I want to engage you. You know your need. You, because the needs do not make community better. You know, I don't want to engage your alcoholism. I want to engage Pedro. And I want to engage Pedro, the dad that cares about his family, that happens to have a problem, a drinking problem, but he's not the problem. He is Pedro. And promotores know how to engage Maria. Maria, the mom that is making tamales to pay the university. And so it happens that Maria has diabetes, but I'm not engaging your diabetes. I'm engaging you. So we don't engage diabetics. We engage people. So it is important to unlearn because the way we have learned is that they are diabetics, that they are depressed, that you are your problem. And if you are your problem, we could finish this conversation now. You are your strength. You are your spirit. You are your dreams. And that's what we engage. And then the fourth one is to create mechanisms for families to transform their communities, right? So these are the promotores in training. They receive a lot of training and promotores know what they do and they also learn what they are not. So we know, we train on diabetes. We have a diabetes self-management program with great outcome, amazing outcome, but we are not endocrinologists. So we know when to send people, we connect people with medical homes. We do one-on-one on emotional health. We have a lot of work on emotional health and depression, but we are not clinical psychologists. So promotores are, people say, so promotores are like small positions? No, we are great leaders. Promotores are not a small nothing. They are amazing individuals. And this is Teresa who has a third grade education and contacted us because she was suffering depression. And we engage Teresa and Teresa became a volunteer and then Teresa became a promotora. And as a promotora, Teresa has been giving her heart and her wisdom to the entire community. Depression didn't do anything for this community, but her strength did. These are our kids. We have a children promotor program with 200 children knocking at the doors in Santa Ana and parts of Anaheim talking about mental health, telling people that this is an apple. My name is Juanita, I'm eight. And do you have a main note? Yes, well, here is an apple and I just want to tell you that apples are better than pizzas and kids like me prefer pizza, but you shouldn't give me pizza. Thank you so much. So that's the message, right? So like you are putting apple juice in this type of bottle where you use things to clean the floor and kids like me can get confused and poisoned. So these children promotores are amazing. They come from those neighborhoods and they join these pipelines, pipelines of where they learn and act and reflect and become youth leaders and then adult leaders and they are not afraid of leading. These are some of the kids in another children promotor program. This is Don Alex, our oldest promotor, he is 79. And that was the founder of Alcoholic Anonymous in Orange County, Alcoholic Anonymous in Spanish and he's very respected. It's one of our promotores doing door to door, door to door markets, the kids are joining. We do fairs, we invite people to learn if they have a condition because we have the program, we have a curriculum, we have outcomes, but at the end of the day, if we really want to transform our communities, we cannot do it without the community. So we invite them to participate. This is Soledad, came as a victim of domestic violence. Teresa came as a person with diabetes, as a non-compliant patient from one of the local clinics and sent her to us so we can tell her how it is. And then we realized that people were going blind in the classes. One person went blind and we asked, we went to the hospital check on her and we asked, are you being screened for diabetic retinopathy? And she said, no. So we asked why they were not screening in that clinic and they said, well, because we don't want to be liable for the treatment and that was happening all over. This was 1994. And we asked the people, and they said the clinic said, we don't want to ask people, we don't want to tell them because they don't have the money to pay for anything. So it might be unethical to tell them about something they cannot tell. And then we took this to the people and said, you know, would you like to know? Would you like to know? And people said, yeah, I would like to know. Well, what would you do if you don't have the money? You know what? I will sell my refrigerator, I will sell my furniture, but I will have that surgery. Another person said, I will go back to Mexico and I will see how I will figure out how to come back. And then one person said something that the Mexican community say a lot. When they want to say, I'm going to do something, they say, I will do that even if I have to sell tamales. So this guy said, I would have that surgery even if I have to sell tamales. And we said, okay, then we started selling tamales and paying eye surgery with tamale money. This is our senator making tamales and this is the participant having his eyes checked and then surgery after that with tamale currency. And the doctors are amazing and they are now discounting, giving us half price. They know that. So there are some assumptions that we have. People are leaders, they want the best for their kids. I haven't met the first mom ever that wants their kids to be killed or joining gangs. Not the first one and I ask that question all the time. Is there any mom here that wants her kid dead? Kill? Joining a gang, dropping from school. Okay, then we're cool. Let's continue the conversation. Haven't met one. So when people say, that's what they want, I don't know who they are talking about. Haven't met once. We produce data because we need data about the place. Not general data. We have the obligation to produce data for that place because we went to school to produce data. So talking about the community experts and the technical experts. Can universities and hospitals produce place-based data that can help monitor the inequity and then the movement towards equity. So we try to produce data and we go out and outreach people and let them know what's going on. They need to know so they can make informed decisions. So this is us providing soap, giving soap to people. So people learn that we are giving soap for free and when they come we say, there is a saying in Spanish, sounds better when I say in Spanish than the Eastern. La ropa sucia se lava en casa, the dirty clothes is washed at home and then we talk about secret with this activity. And with this one we give tortilla and we tell people, tortillas are part of our culture, violence is not. And they get people come to get their tortillas and they get our card and a conversation about peace at home and in our community. And Teresa, the third grader, is teaching here brain development, brain development. I'm talking about really what is the research saying about the brain of our kids and this is our healthy weight program in which we actually teach people how to eat and we teach people about how to count carbs and calories and all of that, but it's not enough. So I love condoms, but I just think it's not enough. I love the little water with salt and sugar, but it's not enough. So we do this, but we also go upstream a little bit every time more and more. If we don't do upstream interventions, if we don't move upstream, it's like receiving kids that are dead here where we work every day and never asking ourselves, where are these dead kids coming from? We are going to the place where something is happening that you are receiving here, dead kids. What's happening there? We need to go upstream to see what's happening. If you only do short-term interventions, people will continue developing diabetes and other conditions. If you only do long-term, people are going to die today. So we need to have a combination of strategies and this one is a parking lot where we do a gym for kids that don't have where to play and we have, you know, this is Gina, one of our promotoras doing home visits. We use the street, we take back our street and the women just walk the street and we have created a wellness corridor as a result that I'm going to show you. This is Irma for those of you that saw my TED med talk and where we talk about Irma. And Irma, the person with diabetes, came to our classes, organized the plans to create a park and we created something that is called, in our framework, Hope Energy Project. And they are called Hope Energy Action Project because this type of project convince you that actually you can change things. Little projects, a dancing project, a craft project, something that can allow me to test my ability to change and help others. So we created this project. We were determined to create a park and we started fighting for a park. Getting organized, advocating, identified a lot, found the partners, invited the community to help so they came and gave us their talents. You know, dancing, singing, we created a committee and here you have a community committee that didn't give up. They were at the table all the time and finally we got the money and built the park. And this park cost 3.6 million, was open in 2013 and at the end of that process, the question was, hmm, what are we going to do next? Because we were ready to have another park and another park and there is another park opening soon inside the school. This is our park. This is the wellness corridor. Now we have our building and the park in the same street and we open a wellness corridor that can invite people to be more active and to be better and this is our Santana today. This is the first club, the biking club, now changing the rules and influencing the whole transportation part of the general plan of the city so we can have bike lanes. This is the gardening. Now we have urban gardens, micro farms, partners and of course a huge component with the youth, you know, training our leaders. The strategies on policy are very clear. We invite the community to be part of everything because the community leaves the data and I love to say that and I'm going to repeat it. I mean the data that we read about, the data that we publish, the people that leave that data usually is not at the table. So the analysis and all of that is done without the people that leave the data and it's not even presented to them because we assume sometimes that people will not understand the data and of course they will not understand if you talk about a standard deviation and p-value but in reality the information where we are putting all of that p-value and all of that the information belongs to them. One of our promotoras always say your grant is my life and your outcomes are my kids. So we have to have a way in which we talk that is like in the middle of the ground right there. And they have the knowledge and at the end of the day if they know and if they are involved they will stay and they will transform their community. So this is the community now coming to receive the report about all the data that was collected by them with us and prioritizing what to do next. What to do next. And these are some of the promotoras using popular education methods, popular theater to talk about something related to housing. Housing and eviction, they wanted to create a dialogue about housing so they used theater and now we have the community talking about what are we going to do? Who are we going to contact? One of our big, big wins lately has been to influence the strategic plan of the city. So how it goes. Every city, and by the way you have great things happening in San Antonio. We have been reading a lot about what's going on here. We have a lot to learn. Maybe you will say well a lot to go. But there are things that are working pretty good here in many of these areas. The strategic plan of the city will guide the general plan. The strategic plan will guide the amount of money that the city puts into parks, safe streets, lights. So if the strategic plan doesn't include our neighborhoods, the ones that are going to get electricity or lights or good sidewalks are the others that are at the day. So we have to be at the table saying my neighborhood has been neglected for 30 years. I live in the darkest neighborhood in Santa Ana. We need this, we need electricity or the plumbing and we want that strategic plan to say that we are going to change the way police relate to us. Because police relate to us as criminals. And my kids are not criminals. We want community policing. So for the community to say that we need to work in what is community policing. So we need to have them at the table way before. So we can inform the strategic plan. 300 people from this community stayed during the conversation every week, every week. And proposed 20 items and 18 were approved by the city of Santa Ana. The thing here now is how do we monitor that? So it gets implemented. Because the majority of people at the table are people that work two, three jobs. So how do we stay there to make it happen? And now the general plan will come. So these are the community participators. So in sum, our strategies are short term and long term. We work on systemic change. Our interventions are comprehensive. We include the community in everything, in every strategy. Inside the agency we like to think that we have an accounting department for the money and an accounting department for the mission. Promotoras are the accounting departments for the mission. We hire them, we pay them, we give benefits to them and they inform the strategy. Same level. With the struggles, sometimes we have power issues and the ones that have university degrees want to overpower the promotora. And then the promotoras will say this is happening and we deal with it and continue learning and unlearning as we say. Abandoning practices that are not working anymore. We are where people live and we focus on the inequity. And we asked for some money a few years ago from the Board of Supervisors in Orange County and one of the supervisors said that they were not going to give us money until we change our name and eliminate the word Latino from our name. And some people think that that is a good idea. American, if you eliminate the word Latino from your name then maybe you can get money from a lot of people. Which is not true. Because people that don't give us money or don't support us, they don't do it not because the name, but because what we do. Because we have a position, we are not neutral. We're committed to fighting inequities. And we're committed to fighting inequities in ways that honor autonomy, self-determination, respect, justice and equity. And that's why we might not get all the support that we need which is fine because my father, as you, the ones that saw the talk heard, my father was a chemistry teacher. And since I was little he said that neutrality is a chemical concept, not a social concept. Has to do with acid and alkaline, you know. And if it changes colors and if it doesn't change it's neutral, but I'm not neutral. And so we are where people live. And we create partnerships because without collaborations we cannot do this either. So I'm going to end there to see if we can entertain few questions. Thank you so much. Because I'm here sitting in the front row I'm gonna take advantage and ask the first question and I'm sure other people are thinking about their questions and I wanna remind you there's a microphone over there and there's a microphone over here and this microphone's not on. So I will speak up, thank you Dr. Morrow. So think about your questions and in the meantime I would like to ask America, you mentioned that the promotores are paid. Yes. Are there also standards of qualifications for the promotores and how did that get implemented? How does that work? Excellent question. So, there is a national conversation about these standards for the promotores. And the idea that promotores need to be certified, for example, which in Texas they are, they need to be at least to some degree, for some level, came from the times of Alma Ata. When promotores were hired to do clinical work and they do. In Venezuela, they do clinical work. In the United States, they don't do clinical work. So a standardization of promotores have become a way of medicalizing promotores. So now I'm going to standardize and what you need to know to be a promotor is the following and not only that, I'm going to tell you what you need to know. Which means that it's against the whole idea that you are a community expert. If you are a community expert, I'm going to invite you to be part of the solution. But if I invite you to be part of the solution and then I tell you what I'm going to tell you what to do and I'm going to tell you the standards. So there's nothing you can do. You have people that don't have idea about community work certifying promotores. And what are they going to certify? The main characteristics of a promotor is their concern for social justice. Is their ability to be there, to create relationships. How do you certify that? So what can you certify? So if the promotor is going to be in the diabetes program, then you probably need to certify that they know how to do that. But are you going to certify the skills or the promotor? So for all of these years, we have had the conversation about what if you are going to do HIV counseling, let's certify that. CPR, first aid, let's certify that. But the promotor is a coach trainer. The promotor is not the one that needs to receive the training alone. In other words, we can say, well, if the promotor needs to be certified, who certifies the people supervising the promotores? And who certifies the institutions working with promotores? That they are able to use promotores. Who certifies that these institutions is really committed to healthier places? Or are they getting promotores only to get a grant? And who certifies, again, is the issue of power. Is the issue of... So the way we have handled it is by coming up with three very important documents. The first one are the principles of practice. These are the principles of practice that guide our work. Two, 18 competencies that we find are crucial to do this work right. These are the 18 competencies. And we have to find that with them. You know, you need to know how to do this and this and this to this level. And the third one is that we believe that the personal and the professional is one. And that when promotores come and they care about the community and they do a raffle to raise money to help someone with the rent, that's also part of what they do. That the personal and the professional is one. That is not true that you can leave your personal out. I was saying that in my previous talk. When I went to medical school, that was one of the things they said the most. Leave your personal out. And I used to ask, out where? Do you have a place where people leave their personal before coming to the hospital? And if so, is that where you leave yours? And what happened when you leave the personal out? What else is out? Your passion, your dream is out. So who comes in? So instead, we created a third document that talks about the expectations in terms of the personal in your workplace. So we might as well talk about it. So those three documents guide our work. We do promotor training. Promotoras are part of the team. We believe that there are many organizations doing this and doing it right. And I would invite anyone working with promotoras to find out what are the agencies that work with promotoras and do the training. If the promotor certification thing goes into college, then the recruitment becomes a problem because now organizations around are going to assume that if this person is the graduate of that promotora certification program, that promotor has the characteristics that change. And it's not necessarily true. The only thing that she has is a diploma. But what she needs is humility, a deep conviction that she's equal to others, a deep concern for social justice, and the readiness to be there for others. And that cannot be certified. So I don't know. I extended my measure of success in a way that satisfies funder. Okay, so we have a Department of Evaluation. So Latino Health Access is this institution. And we are immersing the community, which is here, right? So we are institution and we are community to extend. So we have a lot of obligation, not only with funders, but with workers comp. And we have to reduce liability and do all of that. So we have a Department of Evaluation in the hands of a PhD that knows a lot about evaluation. We create our tools with promotores and we measure everything. We have a diabetes program and we measure lipids, blood pressure, hemoglobin A1C, weight. We have a healthy weight program and all the indicators that you can imagine, we measure that. And we have indicators of wellness, of well-being, depression scales, all of that. But we also give importance to other things and try to educate our funders. For example, we try to educate our funders in the fact that we don't target communities. We partner with them. We educate our funders in an area where they ask for needs. What are the needs of that community? And we say, can we also share what is good about our community and our strength? And we add to all of those indicators, the clinical indicators, other indicators. There are many indicators of success. For example, if you have a group of individuals that come to your activities and they don't leave, your retention is high and you want to share why and you want to analyze why, you can gather data on that. We gather data asking parents, what are the things that you have learned that you use to help your kid lose weight? And the parents say, what has helped me the most is this. And then we ask, where were you before? Before, I think I was here. Then we talk about that. And that has a lot of value for the funder. So you have to be open to creating tools that allow you to measure the real thing, not just to measure, but important measures. Yes, I was wondering how your team manages the self-care and the burnout for the promoter with the difficult work that they do each day. Right. So it's one of our principles of practice that we take care of our team. So we have actually with us a friend who is a clinical, is a therapist that did the training with me today. And we all are there for our team, not just for the promoters, but for everybody. We do retreats very often. We actually, in our supervision model, we talk about supportive supervision. We talk about the financial supervision, the administrative supervision, and the human supervision. Promoters will come from doing a survey, wanting to cry about what they saw, and they will cry. And we celebrate, and we celebrate birthdays, and we celebrate, and we go to each other homes, and we go to the mountains, and we do yoga, and we have a wellness program in the agency. We take very seriously this question about who healed the healer, very seriously. And we discuss books, and again, we pay benefits, and we pay vacations, and you name it. I mean, this is our workforce, and we are working hard to increase salaries all the time. And so it's a level of solidarity that is amazing. We can shelter each other if one of us is suffering. So it's a high level of care, and I will say. So I think that's a beautiful, beautiful phrase to end our evening on. We can shelter each other if one of us is suffering. And I wanna thank everybody for your attendance to this evening, and for your participation in the discussion, and thanks. Let's join me, please, and thank you. Thank you so much for your question. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Well, anything about hand-of-life preparation or finding? I do college affairs, and they're different models for trying to increase people understanding.